“Sip of Tea” FAM Intake Form Date MM DD YYYY Name (what would like me to call you?) Email * What are your preferred pronouns? Location: Phone (###) ### #### Date of Birth Age Height Weight Occupation Heritage Where/From whom did you hear about me? GENERAL Please answer the following questions about yourself! What are your goals for our work together? Are you currently cycling In other words, do you have periods? Yes No What is your history with Cycle Tracking? Are you in a supportive relationship? Yes No CHARTING If you currently chart your cycle, please answer the following questions Where/From whom did you learn to chart your cycle? What fertility signs do you track? How do you keep your information (paper/apps)? Do you have any questions about your charting practice? Perhaps, anything you'd like to be more clear? BIRTH CONTROL / CONTRACEPTION Please share a bit about your history with contraception What is your history with birth control (type, length)? What form(s), if any, are you using currently? On a scale of 1-10, how would you rate your 'pregnancy intention'. 1 - I want to be pregnant NOW. The sooner the better 10 - NEVER want to get pregnant. I will terminate a pregnancy if it happens 1 - I want to be pregnant NOW. 2 3 4 5 6 7 8 9 10 - NEVER want to get pregnant. CYCLES (cycle= entire cycle menses/ovulation/day one to day one) (menses= bleeding time) Please answer if you are currently cycling, or if not, you may answer in regards to past cycles you've experienced When did you last cycle/period begin (name the date as best you can) How regular are/were your cycles? (check one) Very regular Variable (list range on comments below) Definitely Irregular (list details on comments below) I only bleed_____x/year (list comments below) Comments: If currently tracking... how many days of cervical fluid do you normally see each cycle? don't know 1-2 3-5 6-10 MENSES Please share about your bleeding time Heavy / Medium / Light flow? Heavy Medium Light Average length of bleeding time What color would you say your blood is? bright red dark red pink brown What pattern does your blood flow in? light, heavy, medium, light, spotting heavy, medium, light, spotting heavy, light... medium, light... light only What does a 'heavy' day of bleeding look like to you? I fill 2 or more menstrual cups in a day I go through a tampon or pad every few hours I fill one menstrual cup in a day I use a few pads/tampons in a day I may fill one pad or tampon in a day I only need panty-liners on a heavy day How would you rate the pain on a scale of 1-10? 1- Not Painful 2 3 4 5 6 7 8 9 10- Very Painful Cycle Health and History What specific questions/comments or concerns do you have about your cycle? At what age did you begin bleeding? If you have experienced peri-menopausal symptoms or transitioned through menopause, at what age did that happen? Are you aware of what age your mother was when she experienced menopause? Do you have any reproductive issues you would like me to know. Do you use a lubrication during sexual relations and if so, what type? Pregnancy Achievement & Pre- Pregnancy Achievement Answer if this section apply to you Pregnancies; Dates and Outcomes (includes live births, pregnancy losses and terminations) If you have had a pregnancy loss or termination, do you feel resolved about it? Yes No Comments: Are you currently breastfeeding? Do you have any known conditions regarding your fertility? Was there testing? How long have you been ‘trying’ to conceive and how actively? GENERAL HEALTH Please list all other health issues or conditions (even if you think they wouldn’t be relevant) . Are you currently taking medications for these conditions? Please list. Are you content with your body as it is? very much so for the most part I'm neutral about it not so much not at all Were you breastfed as a baby? For how long? How would you describe your digestion? How often do you have a bowel movement and how would you describe it? (ex: hard pebble like, unformed...) What type of diet do you eat? (e.g., Omnivore,Vegan, Keto, WAPF, Paleo, etc.) How much water do you consume each day on average and where do you source your water? (filter, tap, spring, well...) Do you consume caffeine and if so, in what form and how much/often? Do you have any significant chemical exposures due to work or living conditions? (example- living near orchards, house-cleaning with conventional products, etc...) Were you vaccinated as a child and have you received boosters as an adult? Did this include the Gardisil vaccine? No Yes vaccinated as a child and as an adult Vaccinated only as a child Received the Gardisil HPV vaccine How many hours of sleep do you get each night on average? How well do you sleep? Any troubles? What is your stress level? What stress relief tools do you utilize? How strong would you consider your libido (sex drive) to be? Above Average Average Below Average Do you feel you have the resources to receive the healthcare you desire? Please share what types and what frequency that you exercise: Do you receive regular bodywork or preventative care? Are you open to making dietary/lifestyle changes to shift your reproductive health? Yes No Maybe Consent Agreement I understand that attending this consult/class does not guarantee that I or my partner will have the desired outcome we are seeking. I further understand that if I have any questions or problems that I should contact my instructor or other health care practitioner. I thus release all liability of my teacher. I understand that using this method for contraceptive purposes, even when used correctly, can fail. I am aware that recent studies performed in Germany using a very similar method (Sensiplan) have been shown to be 99.4 and 99.6% effective with "perfect use" and 98.4% with typical use. I understand that these rates are highly dependent on the learning model, the teacher, the student's comprehension and many other factors. This particular study utilized a very controlled population so may indeed have a falsely high 'typical use' rate compared to other cultural settings. I claim full responsibility for my use of this method and the information received in this consult, as well as for my own health. I further understand that any information disseminated in this class is for the purpose of education and is not intended to diagnose, cure or treat disease. Consent Signature * Date MM DD YYYY Partner's Consent Signature (if present) Date 2 MM DD YYYY Use of Material for Educational Purposes (OPTIONAL) I grant permission for Saphira "Safi" Contreras, FAE, at 'Soul Center', to use my charts and client information to further FA education in the world. She may share my charts (anonymously) with future students while teaching. My privacy will ALWAYS be respected and strict confidentiality will be upheld. Material Usage Signature Thank you for the time. Looking forward to working with you .
